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Medicare Advantage: HMO: Advantages/Disadvantages Compared To Original Medicare


There are both advantages and disadvantages to a Medicare Advantage HMO compared to Original Fee-For-Service Medicare. 

Advantages  The advantages are:

  • Cost: A Medicare HMO is required to cover, as a minimum, the same medical costs that Original Fee-for-Service Medicare covers, but the services are provided in an HMO setting. That means that while you must obtain all of your care from network medical providers, you usually will pay only a small co-pay such as $5.00 per visit and nothing for additional services such as X-rays, lab tests or hospital stays. The result is usually that your out-of-pocket costs are much lower under an HMO than a Fee-for-Service Plan.
  • No paperwork
    • There is little or no paperwork in an HMO. There are no claim forms for you to complete.
    • You pay the doctor or other health care provider a co-pay at the time of service.
  • Coordinated Care: All medical care is coordinated through a Primary Care Physician who oversees all your treatment. (To learn how to choose a primary care doctor, see: How To Choose A Primary Care Doctor.)
  • Prescription Drugs: Medicare HMOs have to offer drug coverage at least equal to the coverage provided under Medicare Part D. Some HMO plans offer coverage that Medicare Part D doesn't.
  • Other benefits: In an effort to attract members, most Medicare HMOs will offer at least some additional benefits that are not covered by Original Fee-for-Service Medicare, such as preventive health care, eye exams, eye glasses, hearing tests, hearing aids, and even dental coverage. 


  • Medicare HMOs have the same drawbacks as other HMOs.
    • Your choice of doctors is limited to members of the HMO's network of contracting doctors.
    • Medical care may be required to go through the Primary Care Physician (PCP).
    • You will not be covered if you see a doctor or receive care outside the HMO's network (except for Emergency or Urgent Care). To learn more, see: Medicare Advantage HMOs: Special Rules.
  • Coverage is usually limited to emergency and urgently needed treatment if you are traveling outside the HMO's service area. 


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